St George's German Lutheran Church, 55 Alie Street, London E1 8EB Tel: 020 7481 0533 Fax: 020 7488 3756 hct@hct.org.uk Registered Charity Number: 1017321
	Application to become a Friend
	PLEASE PRINT, FILL OUT AND RETURN WITH REMITTANCE TO THE ABOVE ADDRESS
	I/we wish to apply for:
	.......... Individual membership (£10 per annum) .......... Joint membership (£15 per annum) .......... Life membership (£250) .......... Corporate membership (£50 per annum)
	I enclose cheque/ have completed Gift Aid Declaration*/standing order* (see below) for £.....................
	Surname................................................ First Name .............................. Title .....................
	Address .................................................................................................................................
	...............................................................................................................................................
	Profession/special interests ................................................................................................
	Signed ...................................................................................................................................
	Gift Aid Declaration completing this enables us to reclaim income tax on this gift from Inland Revenue
	Name ....................................................................................................................
	Address .................................................................................................................
	...............................................................................................................................
	I am a UK taxpayer and wish all my donations after 6 April 2002 to and through the Historic Chapels Trust, to be treated as Gift Aid.
	Signed ............................................................................................. Date .............................
	Standing Order Instruction the amount remains the same and should subscription rates change you have to set up a new standing order
	To the Manager ..................................................................... Bank plc at ..............................................................................................................................................................
	Please pay to the Royal Bank of Scotland plc, 29 Old Brompton Road, London SW7 3JE sort code 16 00 84 for the credit of Historic Chapels Trust, account number 14915117 the sum of £ ............ (in words) ....................................... On the 1st day of January 20..... *and a like sum on the .......................................................................................... *and a like sum on the same day in each succeeding year, until further notice and debit my account no. ...................................................................................... *delete as appropriate This cancels any existing instructions.
	Signed .....................................................................................................................
	Name ......................................................................................................................
	Address ..................................................................................................................
	When you have completed this form please return it to the Historic Chapels Trust, St George's Lutheran Church, 55 Alie Street, London E1 8 EB. After registration it will be forwarded to your bank.
	Company Number: 2778395. Registered Charity Number: 1017321